Human Papillomavirus - Vulvovaginal Infections

Human papillomavirus (HPV) infection is sexually transmitted and is the most common sexually transmitted disease (STD) among young, sexually active persons.

HUMAN
PAPILLOMAVIRUS

Human
papillomavirus (HPV) infection is sexually transmitted and is the most common
sexually transmitted disease (STD) among young, sexually active persons. An
estimated 5.5 million people become infected with HPV each year in the United
States (U.S. Surgeon General’s Report, 2001). More than 80 strains exist, some
of which are associated with cervical abnormalities, includ-ing dysplasia and
cancer. Infections can be latent (asymptomatic and detected only by DNA
hybridization tests for HPV), subclin-ical (visualized only after application
of acetic acid followed by in-spection under magnification), or clinical
(visible condylomata acuminata). The most common strains, 6 and 11, usually
cause condylomata (warty growths) on
the vulva. These are often visi-ble or may be palpable by the patient.
Condylomata are rarely pre-malignant but are an outward manifestation of the
virus. Strains 6 and 11 are associated with a low risk for cervical cancer.
Some strains may not cause condylomata but affect the cervix, resulting in
abnormal Pap smear results. For example, strains 16, 18, 31, 33, 35, and 45
affect the cervix. Their effects are usually invisible on examination but may
be seen on colposcopy. They may cause cer-vical changes that may appear as
koilocytosis on Pap smear or ab-normal smear results. These strains are
associated with a higher risk for cervical cancer (U.S. Surgeon General’s
Report, 2001).

The
incidence of HPV in young, sexually active women is high. Risk factors include
being sexually active, having multiple sex partners, and having sex with a
partner who has or has had multiple partners. Alcohol consumption and drug use
are risk fac-tors, as both impair careful decision making, judgment, and
self-care (Association of Reproductive Health Practitioners, 2001).

Medical
Management

Treatment
of external genital warts includes topical application of trichloroacetic acid,
podophyllin (Podofin, Podocon), and chemotherapeutic agents. Interferon
injections are also used in treatment. These agents are applied by the health
care provider. Topical agents that can be applied by the patient to external
le-sions include podofilox (Condylox) and imiquimod (Aldara). Be-cause the
safety of podophyllin, imiquimod, and podofilox during pregnancy has not been
determined, these agents should not be used to treat pregnant women.
Electrocautery and laser therapy are alternative therapies that may be
indicated for pa-tients with a large number or area of genital warts (Centers
for Disease Control & Prevention, 2002).

Treatment
usually eradicates perineal warts or condylomata. However, they may resolve
spontaneously without treatment and may also recur even with treatment.

If the
treatment includes application of the topical agent by the patient, she needs
to be carefully instructed in the use of the agent prescribed and must be able
to identify the warts and be able to apply the medication to them. The patient
is instructed to anticipate mild pain or local irritation with the use of these
agents (Centers for Disease Control & Prevention, 2002).

Patients
with HPV should have regular Pap smears, possibly every 6 months for several
years, because of the propensity of HPV to cause dysplasia (changes in cervical cells).

Much
remains unknown about the subclinical disease and la-tent phase of the disease.
Women are often exposed to this virus by a partner who is unknowingly a carrier.
Condoms can prevent transmission, but transmission can also occur during
skin-to-skin contact in areas not covered by condoms. In many cases, patients
are angry about having warts or HPV and do not know who in-fected them because
the incubation period can be long and part-ners may have no symptoms.
Acknowledging the emotional distress that occurs when an STD is diagnosed and
providing support and facts are important nursing actions.